Several anomalies can cause the bladder to develop abnormally and require surgical augmentation. Conditions such as posterior urethral valves, bilateral ectopic ureters, bladder extrophy, cloacal extrophy, and spina bifida (ie, myelomeningocele) may cause the bladder to be noncompliant, resulting in a small capacity bladder that generates high pressures. Clinically this causes patients to suffer from incontinence while increasing their risk for renal failure due to the high pressures in the genitourinary system. The current standard of therapy for these pediatric patients is bladder augmentation through enterocystoplasty (Lewis et al. Br. J. Urol. (1990); 65:488-491). Bladder augmentation involves the removal of a section of large bowel from the patient who then has that tissue connected to the existing bladder to increase compliance, decrease pressure, and improve capacity. The surgeries are relatively complex and expensive. Even in patients with a good technical result, the procedure is associated with numerous immediate risks and chronic complications. The invasiveness, cost, and complications of these surgeries limit their use to only the most severe bladder deficiencies. A similar surgical procedure is performed in adults who require a bladder replacement, many as a result of bladder cancer. In adults, the entire bladder is resected and replaced with large bowel. Despite the risk of adverse effects, there are approximately 10,000 of these procedures performed per year in the United States, including about 10% in children with congenital abnormalities and 90% in adults with acquired disorders such as bladder cancer. There is clearly a compelling medical need for an improved approach that would eliminate or at least substantially reduce the adverse effects associated with the current standard of care.
The human urinary bladder is a musculomembranous sac, situated in the anterior part of the pelvic cavity that serves as a reservoir for urine, which it receives through the ureters and discharges through the urethra. In a human the bladder is found in the pelvis behind the pelvic bone (pubic symphysis) and is above and posteriorly connected to a drainage tube, called the urethra, that exits to the outside of the body. The urinary bladder is subject to numerous maladies and injuries which cause deterioration of the urinary bladder in patients. For example, bladder deterioration may result from infectious diseases, neoplasms and developmental abnormalities. Further, bladder deterioration may also occur as a result of trauma such as, for example, car accidents and sports injury. Urinary diversions are often necessary in bladder cancer patients. There are over 54,000 new bladder cancer cases each year in the United States of America. Most bladder cancers are of epithelial origin, and worldwide, there are approximately 336,000 new cases of urothelial carcinomas (transitional cell carcinomas (TCC)) annually (Kakizoe (2006) Cancer Sci. 97(9) 821).
Urinary diversion is a way to route and excrete urine from the body when an individual is unable to urinate due to a damaged or non-functional urinary system. In general, any condition that blocks the flow of urine and increases pressure in the ureters and/or kidneys may require a urinary diversion. Some common indications for diversion include cancer of the bladder requiring a cystectomy, a neurogenic bladder that impact renal function, radiation injury to the bladder, intractable incontinence that occurs in women, and chronic pelvic pain syndromes. In general, two major strategies exist for urinary diversion: a urostomy and a continent diversion. A urostomy involves the creation of a stoma in the abdomen which is connected to a conduit inside the body such as a short segment of the small intestine submucosa (SI) such as the ileum, colon or jejunum. In this procedure, the other end of the short SI is connected to the ureters which normally carry urine from the kidney to the bladder. Urine flows through the ureters into the short SI and out the stoma to an external collection reservoir. An alternative of this procedure is the attach the ureters directly to a stoma, also called a ureterostomy. A continent diversion involves the creation of a pouch or reservoir inside the body from a section of the stomach or small or large intestine and the use of a stoma may or may not be required. For example, a continent cutaneous reservoir may be created by obtaining a segment of the bowel and modifying it into a more spherical shape. One end of the modified segment is connected to the ureters and the other to a stoma that leads to an external collection reservoir. Finally, an orthotopic diversion may created by placing the re-shaped segment in place of the original bladder by connecting one end to the ureters and the other end to the urethra so the individual may urinate through the urethra instead of through a stoma.
Although small intestinal submucosa (SI) may be used for urinary diversion, it has been reported that the removal of the mucosa and submucosa may lead to retraction of the intestinal segment (see, e.g., Atala, A., J. Urol. 156:338 (1996)). Other problems have been reported with the use of certain gastrointestinal segments for bladder surgery including stone formation, increased mucus production, neoplasia, infection, metabolic disturbances, long term contracture and resorption. The use of natural materials for urinary diversion has shown that bladder tissue, with its specific muscular elastic properties and urothelial impermeability functions, cannot be easily replaced. In addition, the use of a patient's own bowel segments for urinary diversion requires at least two different surgical procedures where a first surgery is performed to remove a segment and a second surgery to install the urinary diversion. The requirement of multiple surgeries increases the overall cost of the procedures, the risk to the patient, and patient's overall comfort.
Therefore, due to the multiple complications associated with the use of gastrointestinal segments for urinary diversion and requirement for multiple surgical procedures, there exists a need for methods and devices for providing urinary diversion systems to patients in need of such a system.
Urinary incontinence is a prevalent problem that affects people of all ages and levels of physical health, both in the community at large and in healthcare settings. Medically, urinary incontinence predisposes a patient to urinary tract infections, pressure ulcers, perineal rashes, and urosepsis. Socially and psychologically, urinary incontinence is associated with embarrassment, social stigmatization, depression, and especially for the elderly, an increased risk of institutionalization (Herzo et al., Ann. Rev. Gerontol. Geriatrics, 9:74 (1989)). Economically, the costs are astounding; in the United States alone, over ten billion dollars per year is spent managing incontinence.
Incontinence can be attributed to genuine urinary stress (bladder and urethra hypermobility), to intrinsic sphincter deficiency (“ISD”), or both. It is especially prevalent in women, and to a lesser extent incontinence is present in children (in particular, ISD), and in men following radical prostatectomy.
Stress incontinence is an involuntary loss of urine that occurs during physical activities which increase intra-abdominal pressure, such as coughing, sneezing, laughing, or exercise. A person can suffer from one or both types of incontinence, and when suffering from both, it is called mixed incontinence. Despite all of the knowledge associated with incontinence, the majority of cases of urge incontinence are idiopathic, which means a specific cause cannot be identified. Urge incontinence may occur in anyone at any age, and it is more common in women and the elderly.
The detrusor is the bladder wall muscle that contracts to expel the urine from the bladder. Consequences of detrusor malfunction such as hyperreflexia include poor bladder compliance, high intravesical pressure, and reduction in bladder capacity, all of which may result in deterioration of the upper urinary tract.
One current treatment for urge incontinence is injection of neurotoxins, such as botulinum toxin, e.g., Botox®. It is thought that botulinum toxin exerts its effect on bladder hyperactivity by paralyzing the detrusor muscle in the bladder wall or possibly impacting afferent pathways in the bladder and reducing sensory receptors in suburothelial nerves. The large size of the botulinum toxin molecule can limit its ability to diffuse, and thus prohibits it from reaching both afferent and efferent nerve fibers. As a result, current methods of administration for overactive bladder (OAB), for example, require many injections (typically 20 to 50) of botulinum toxin into the bladder muscle wall, thus increasing the number of doctor visits and associated cost of treatment. Moreover, the safety of chronic long-term impact of inhibition of sensory neurotransmitter release from bladder has not yet been determined.
Further approaches for treatment of urinary incontinence involve administration of drugs with bladder relaxant properties, with anticholinergic medications representing the mainstay of such drugs. For example, anticholinergics such as propantheline bromide, and combination smooth muscle relaxant/anticholinergics such as racemic oxybutynin and dicyclomin, have been used to treat urge incontinence. (See, e.g., A. J. Wein, Urol. Clin. N. Am., 22:557 (1995)). Often, however, such drug therapies do not achieve complete success with all classes of incontinent patients, and often results in the patient experiencing significant side effects.
Besides drug therapies, other options used by the skilled artisan prior to the present invention include the use of artificial sphincters (Lima S. V. C. et al., J. Urology, 156:622-624 (1996), Levesque P. E. et al., J. Urology, 156:625-628 (1996)), bladder neck support prosthesis (Kondo A. et al., J. Urology, 157:824-827 (1996)), injection of cross-linked collagen (Berman C. J. et al., J. Urology, 157:122-124 (1997), Perez L. M. et al., J. Urology, 156:633-636 (1996); Leonard M. P. et al., J. Urology, 156:637-640 (1996)), and injection of polytetrafluoroethylene (Perez L. M. et al., J. Urology, 156:633-636 (1996)).
A recent well known approach for the treatment of urinary incontinence associated with ISD is to subject the patient to periurethral endoscopic collagen injections. This augments the bladder muscle in an effort to reduce the likelihood of bladder leakage or stress incontinence.
Existing solutions to circumvent incontinence have well known drawbacks. While endoscopically directed injections of collagen around the bladder neck has a quite high success rate in sphincter deficiency with no significant morbidity, the use of collagen can result in failures that occur after an average of two years and considerations need to be given to its cost effectiveness (Khullar V. et al., British J. Obstetrics & Gynecology, 104:96-99 (1996)). In addition, deterioration of patient continency, probably due to the migration phenomena (Perez L. M. et al.) may require repeated injections in order to restore continency (Herschorn S. et al., J. Urology, 156:1305-1309 (1996)).
The results with using collagen following radical prostatectomy for the treatment of stress urinary incontinence have also been generally disappointing (Klutke C. G. et al., J. Urology, 156:1703-1706 (1996)). Moreover, one study provides evidence that the injection of bovine dermal collagen produced specific antibodies of IgG and IgA class. (McCell and, M. and Delustro, F., J. Urology 155, 2068-2073 (1996)). Thus, possible patient sensitization to the collagen could be expected over the time.
Despite of the limited success rate, transurethral collagen injection therapy remains an acceptable treatment for intrinsic sphincter deficiency, due to the lack other suitable alternatives.
At present, individuals who suffer from Overactive Bladder Disorders or Urge Incontinence are initially treated by physicians with non-invasive pharmaceutical medical products. However, if these non-invasive pharmaceutical products fail, physicians offer a more invasive solution.
Thus, a need exists for a minimally invasive method of enlarging an existing laminarily organized luminal organ or tissue structure, e.g., a bladder.
Tissue engineering principles have been applied to successfully provide implantable cell-seeded matrices for use in the reconstruction, repair, augmentation or replacement of laminarily organized luminal organs or tissue structures, such as a bladder, a portion of a bladder, or a bladder component. As described in Atala U.S. Pat. No. 6,576,019, cells may be derived from the patient's own tissue, including the bladder, urethra, ureter, and other urogenital tissue. However, there are challenges associated with a dependence upon the development and maintenance of cell culture systems from the primary organ site as the basic unit for developing new and healthy engineered tissues. For example, the treatment of a defective bladder poses a particular challenge regarding cell sourcing because it stands to reason that culturing bladder cells from a defective bladder will result in the cultured cells also being defective. Such cells are not a wise choice for populating an implantable neo-bladder scaffold or matrix. As such there is a need for alternative sources of cells that are suitable for seeding on implantable neo-organ/tissue structure scaffold or matrix.
There is a wealth of literature supporting the notion that human adipose tissue is a rich source of adult stem cells (Devlin et al. (2004), Cytotherapy 6:7-14; Awad, et al. (2003), Tissue Engineering 9:1301-12; Erickson et al. (2002), Biochemical and Biophysical Research Communications 290:763-769; Gronthos et al. (2001), Journal of Cellular Physiology 189:54-63; Halvorsen et al. (2001); Metabolism 50:407-413; Halvorsen et al. (2001), Tissue Eng. 6:729-41; Harp et al. (2001), Biochemical and Biophysical Research Communication 281:907-912; Hicok et al. (2004), Tissue Engineering 10:371-380; Safford et al. (2002), Jun. 7, 294(2):371-9; Safford et al, (2004), Experimental Neurology 187:319-28; Sen et al. (2004), Journal of Cellular Biochemistry 81:312-319; Sigal et al. (1994), Hepatology 19:999-1006; Wickham et al. (2003), Clinical Orthopedics and Related Research, 412:196-212; Ashijian et al. (2003), Plast Reconstr Surg. 111:1922-31; De Ugarte et al. (2003), Cells Tissues Organs. 174:101-9; Mizumo et al. (2002), Plast Reconstr Surg. 109:199-209; Morizono et al. (2003), Hum Gene Ther. 14:59-66; Winter et al. (2003), Arthritis Rheum. 48:418-29; Zuk et al. (2001), Tissue Eng 7:211-228; Zuk et al. (2002), Mol Biol 13: 4279-4295, reviewed in Gimble et al. (2003), Cytotherapy 5:362-369). These cells, termed Adipose-Derived Adult Stem (ADAS) cells, exhibit an immunophenotype and differentiation potential comparable to that of MSCs (Gronthos et al. (2001), Journal of Cellular Physiology 189:54-63; Safford et al. (2002), Biochem Biophys Res Commun. 294(2):371-9; Zuk et al. (2002), Mol Biol Cell 13:4279-4295).
Reproducible and efficient methods to isolate adult stem cells from human liposuction specimens are available in the public domain (Aust et al. (2004), Cytotherapy 6:7-14; Halvorsen et al. (2001), Metabolism 50:407-413). The procedure involves collagenase digestion of the tissue, differential centrifugation, and expansion in culture. A single gram of tissue can yield between 50,000 to 100,000 stromal cells within 24 hours of culture (Sen et al. (2001), J Cellular Biochemistry 81:312-319). Analysis of specimens obtained from 20 individual donors resulted in a consistent recovery a mean of 401,000 cells with a viability of 94% from a single ml of liposuction waste (Aust et al. (2004), Cytotherapy 6:7-14). Expansion of these cells can result in a population greater than 500 million cells within a 2 week period from a standard lipoaspirate.
In the presence of dexamethasone, insulin, isobutylmethylxanthine and a thiazolidinedione, the ADAS cells undergo adipogenesis (Sen et al. (2001) Journal of Cellular Biochemistry 81:312-319). The differentiation potential of the ADAS cells is not limited to the adipocyte lineage. Conditions that promote ADAS cell differentiation along the chondrocyte and osteoblast pathways have been reported (Awad, et al. (2003), Tissue Engineering 9:1301-12; Erickson et al. (2002), Biochemical and Biophysical Research Communications 290:763-769; Halvorson et al. (2001), Metabolism 50:407-413; Hicok et al. (2004), Tissue Engineering 10:371-380; Wickham et al. (2003), Clinic Orthopedics and Related Research 412:196-212). In vivo, human ADAS cells combined with a hydroxyapatite biomaterial synthesize osteoid matrix when implanted subcutaneously into immunodeficient mice (Hikok et al. (2004), Tissue Engineering 10:371-380). Substantial data are available to demonstrate that murine or human adipose derived adult stem cells (muADAS and huADAS respectively) cultured in the presence of antioxidants and other mediators undergo morphologic and phenotypic changes consistent with neuronal differentiation (De Ugarte (2003) Cells Tissues Organs. 174:101-9; Safford et al. (2002), 294(2):371-9; Safford et al. (2004), Experimental Neurology 187:319-28).
As described by Jayo et al. Regen. Med. (2008) 3(5), 671-682 (hereinafter referred to as “Jayo I”), attempts to repair organs or tissue have been characterized by incomplete tissue replacement frequently with collagen deposition, and in some cases scar tissue formation. Jayo et al. also observed a more desirable outcome of tissue engineering is regeneration of the original structure and function of a tissue structure or organ. See also Jayo et al., J. Urol. (2008) 180; 392-397 (hereinafter referred to as “Jayo II”). Certain molecules are believed to be associated with the regenerative process in vivo. For example, the chemokine MCP-1 is best known for its ability to recruit mononuclear cells. However, it also appears to be a potent mitogen for vascular smooth muscle cell proliferation. MCP-1 recruits circulating monocytes to the area of vessel injury, which in turn are typically transformed to macrophages that can serve as reservoirs for cytokines and growth factors. Macrophages also ingest cholesterol and oxidize lipids. Macrophages and muscle precursor cells are both believed to be targets for MCP-1 signaling. The CCR-2 receptor is the ligand for MCP-1 (CCL2) and CCR-2 deficient mice show a regeneration defect with enhanced adipogenesis/fibrosis. Sections from CCR-2 deficient mice when challenged with skeletal muscle regeneration demonstrated the following in comparison to normal mice: more interstitial space, a high number of inflammatory cells, large round swollen myofibers, more fibroblast accumulation in interstitial space, fat infiltration with collagen distribution around fat deposits, and fibrosis accompanied by calcium deposition (Warren et al. (2005), FASEB J. 19:413-415; Selzman et al. (2002), Am J Physiol Heart Circ Physiol. 283(4); H1455-H1461; Shannon et al. (2007), Am. J. Cell Physiol. 292:C953-C967; Shireman et al. (2006), J. Surg. Res. 134(1):145-57. Epub 2006 Feb. 20; Amann et al. (1998), Brit. J. Urol. 82:118-121; Schecter et al. (2004), J. Leukocyte Bio1.75:1079-1085; Deonarine et al., (2007), Transl Med. 5:11; Lumeng et al. (2007), J. Clin. Invest. 117(1): 175-184).
The present invention concerns cell populations derived from autologous sources that are different from the organ or tissue structure that is the subject of the regeneration, reconstruction, repair, augmentation or replacement described herein, methods of isolating such cells, neo-organ/tissue structure scaffolds or matrices seeded with such cells (constructs) and methods of making the same, as well as methods of treating a patient in need using such neo-organ/tissue structure constructs.